14-100988 QTY CFA epEcENED PERMIVAPPLICATION
Federal Way MAR 0 4 2014
CITY OF FPERAL WAY
PERMIT NUMBER /q _ L 6 D S Q� L - E p TARGET DATE J'ti
L LL
SITE ADDRESS SUITEJUNIT I
k• W 0 - --DiZ • e" i, , s._ , clSo .,3 k A
PROJECT VALUATION ZONING ASSESSOR'S TAX/ 1 -CEL t
5o0iix � 9_ a_ 1_ 0_ cL - .g_ . L1_
TYPE OF PERMIT ❑ BUILDING ❑ PLUMBING ❑ MECHANICAL ❑ DEMOLITION ❑ ENGINEERING $FIRE PREVENTION
NAME OF PROJECT Q ,u1 Lili
PROJECT DESCRIPTION •Ab 1a C e_ . l i-1 n • �. / ` ,�
Detailed description of work to _ 1 1 __I .L.
be included on this permit only • • - r • I ,• CO t It APIOMINIMIIIIIII
PRIMARY PHONE
PROPERTY OWNER Ur 9(i_LI__I.• l i :I( • - g 8-$$$1
MAILING ADDRESS E-MAIL
. VI- ' qtr--1
ITT STATE ZIP
nor- ne A ' 81 -
T�nctn't , c lee - ro+ ' Olin 111g- 19g- 3413 PHONE
MAILING ADDRES E-MAIL
CONTRACTOR ' ' 10 '—` ' e. 5E- .4- I brouun► t n Ft n It - i .
STATE F ' •■
eel (Ib A- ./ rl- o to- (3y'
WA STATE CONTRACTOR'S LICENSE# EXPIRATION DATE '4/1
\F 1' r • 1 r /., / t / I ) to
NAME PRIMARY • O,
•
1111
.. roteC+ton ,1 ' - 4'l
APPLICANT MAILING ADD- S tti
q 6 tO/S- An 5e- 4 `MI 6 • t ,. ' II I ( .0/4
STATE ZIP FAX
I'' " LOPt a .a: : h7- 8010- 3493
PRIMARY PHONE(
PROJECT CONTACT • . • • ' ri- '. q- 4
G(The individual to receive and i 110 1 1,0(6- �Ve G r 4 , - I L , G
respond to all correspondence 1 1 D Y C7G `� I C 1■. 1 ,�
concerning this application)
I' ' Nall 4ii1AO i i ••_
PROJECT FINANCING NAME ❑ OWNER-FINANCED
,
Required value of$5,000 or more MAILING ADDRESS,CITY,STATE,ZIP PHONE
(RCW 19.27.095)
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner.I certify that to the best
of my knowledge, the information submitted in support of this permit application is true and correct.I certify that I will comply with
all applicable City of Federal Way regulations pertaining to the work authorized by the issuance of a permit. I understand that the
issuance of this permit does not remove the owner's responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
I further agree to hold harmless the City of Federal Way as to any claim(including costs,expenses,and attorneys'fees incurred in
the investigation and def •f such claim),which may be made by any person,including the undersigned,and filed against the city,
but only where such clalarises out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied t•t77 ci • a part of this application.
SIGNATU- DATE ON/4
PRINT NAME: L►,G I ' ' • 014n ,Iice ■
- ......
Bulletin#100-January 1,2013 Page 1 of 3 k:\Handouts\Permit Application